Congestive heart failure

Background

• Assume valvular problem in new-onset CHF
• Assume valve thrombosis in CHF with a prosthetic valve
• Do not give vasodilators in aortic stenosis, HOCM; yes in mitral regurgitation

NYHA Classes

1. No symptoms
2. Symptoms with every day activity
3. Severely limits activity
4. Symptoms at rest

Etiology

• CAD
• HTN
• Cardiomyopathy
• Valvular Emergency
• High-output
• Peripartum Cardiomyopathy
• Cardiac Tamponade
• Dysrhythmias

Differential Diagnosis

• Cardiovascular
  • ACS
  • Acute Valve Dysfunction
  • Aortic Dissection
  • Dysrhthymia
  • Endocarditis
  • Hypertensive Emergency
  • Pericardial Tamponade
• Pulmonary
  • COPD
  • PE
  • PNA
• Other
  • Pure volume overload
    • Renal Failure
    • Post-Transfusion
  • Sepsis

Causes of Decompensation

• Medication noncompliance
• Dietary noncompliance
• Uncontrolled HTN
• MI
• Valvular Dysfunction
• Arrhythmias
• Infection
• Inappropriate medications (e.g., negative inotropes)
• Fluid overload
• Missed dialysis
• Thyrotoxicosis
• Anemia
• Alcohol Withdrawal

Diagnosis

Pitting pedal edema

Pulmonary edema with small pleural effusions on both sides.

• CBC (r/o anemia)
• Chem
• ECG
• CXR
  • Cephalization
  • Interstitial edema
  • Pulmonary venous congestion
  • Pleural effusion
  • Alveolar edema
  • Cardiomegaly
• Troponin?
• Ultrasound
  • Bedside to assess global function, B lines, assessment of IVC
  • Formal TTE/TEE

Brain natriuretic peptide (BNP)

• Measurement
  • <100 pg/mL: Negative for acute CHF (Sn 90%, NPV 89%)
  • 100-500 pg/mL: Indeterminate (Consider differential diagnosis and pre-test probability)
  • >500 pg/mL: Positive for acute CHF (Sp 87%, PPV 90%)
  • Combination of BNP with clinician judgment 94% sensitive 70% specific (compared to 49% sn and 96% spec clinical judgement alone)

NT-proBNP

• <300 pg/mL → CHF unlikely
• CHF likely in:
  • >450 pg/mL in age < 50 years old
  • >900 pg/mL in 50-75 years old
  • >1800 pg/mL in > 75 years old

Treatment

Acute Pulmonary Edema and Hypertensive Heart Failure

See Pulmonary Edema

Hypotensive Heart Failure

See Cardiogenic Shock

Inotropic Agents

• Dobutamine generally first line
• Milrinone if pt on Betablockers
• consider in severe LV dysfunction and low output syndrome
  • dimunished peripheral perfusion and end organ damage
• vasodilatory treatment inadequate response or limited by symptomatic hypotension
• must have obvious evidence of elevated filling pressures
  • JVD, noncollapsing IVC, etc
• Inotropes are not indicated in setting of preserved systolic function

Heart Failure Without Pulmonary Edema

UNLOAD+

1. Upright Position
2. Nitrates - ask about sildenafil
   • start SL 0.4mg delivered over 5 min = 0.15mg/min
   • if no improvment IV NTG gtt, start 0.3-0.5mcg/kg/min, but may increase to 3-5mcg/kg/min
     • Keep BP >95
   • Consider nitroprusside 0.3 mcg/kg/min if HTN or NTG ineffective
3. Lasix
   • hold if no sxs of fluid overload
   • Give nitrates first
   • Give double home dose, or up to 2.5x dose.
     • if lasix 40mg po qd, then lasix 40-100mg IV
4. Oxygen
   • CPAP/BiPAP -give early
5. ACEI
   • Enalapril at 0.004mg/kg as IVB or 1mg gtt over 2hr
     • Avoid in pregnancy, hyperK+
6. Digoxin
   • Indicated for a fib rate control

Disposition

Admission Criteria

CCORT

• 7 day mortality risk score calculator for pts presenting to the ED with decompensated HF
• http://www.ccort.ca/calculator.aspx

AHCPR '00

• ACS
• Pulm edema/resp distress
• O2 sat < 90% on room air
• Severe complicating illness
• CHF refractory to outpt therapy
• Anasarca
• Symptomatic hypotension or syncope
• Arrythmia (e.g. new a. fib)
• Inadequate outpatient support

External Links

• MDCalc - Emergency Heart Failure Mortality Risk Grade (EHMRG)

See Also

• Pulmonary Edema
• CHF Meds